1689261554 NPI number — NU DENTAL OF BARNEGAT

Table of content: (NPI 1689261554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689261554 NPI number — NU DENTAL OF BARNEGAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NU DENTAL OF BARNEGAT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689261554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 RIVERSIDE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLMDEL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07733-2084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-945-7999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
770 LIGHTHOUSE DR # 192-B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARNEGAT
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08005-2373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-879-0036
Provider Business Practice Location Address Fax Number:
609-879-0036
Provider Enumeration Date:
12/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GIZACHEW
Authorized Official First Name:
ADMASU
Authorized Official Middle Name:
N
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
609-879-0036

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0440833 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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